Referral System; A Need of Today
Editorial
Referral System; A Need of Today
Naila Israr
Address of Correspondence: Dr. Naila Israr
Head of Department
Obstetrics & Gynecology,
Federal Govt. Poly Clinic (PGMI),
Islamabad
Email: naila.israr@yahoo.com
The referral is a process by which a health worker
or provider transfers the responsibility of patients-
care temporality or permanently to another health
professional due to its inability to provide diagnostic
and therapeutic intervention as it relates to health
care needs of patient.1 An effective patient referral
system is integral component of an efficient
healthcare delivery setting while promoting a
functional relationship between all levels of health
system. And ensuring that patients receive the best
possible care at appropriate level. And those in
need specialist services access them in timely
way.2
In an effort to provide available care to the majority
of its citizens, the Government of Pakistan
constructed primary health facilities in late 1970s
and mid-1980s. Pakistan boasts an extensive
infrastructure system of over 5000 Basic Health
Units and over 650 Rural Health Centers in rural
areas. Many of these facilities are currently
J Soc Obstet Gynaecol Pak. 2019; Vol 9. No.3
deserted or have been put to other uses. Many
more are in urgent need of repair. These primary
healthcare facilities are supported by almost 700
public sector hospitals. Despite such an elaborate
network primary health care activity have not
brought any improvement. The reason for this
failure is diverse and multi-faceted. Important
among them is absence of properly functioning
referral system.3
There is heavy workload at higher-level facilities,
the underlying assumption is better equipment in
terms of diagnostic and therapeutic facilities. Such
influx affects patient’s management. The referral
can be internal-within the same facility, or external
–from one facility to another and
secondary/specialized investigation, within public
and private hospitals. The referral is a two-way
process and can be upward, downward, or side
wards. A patient can be referred from secondary
provider to tertiary provider (vertical referral), and
from one specialist to another within same levels
(lateral referral).4 Unfortunately such referral is also
not working. A lot of noise by general public and
media was raised on some issues of referral in
major cities.
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Naila Israr
The “Three Delays” model propose that pregnancy-
related mortality is overwhelming due to delays in:
(1) deciding to seek appropriate medical help for
obstetrics emergency (2) reaching an appropriate
obstetric facility, and; (3) receiving adequate care
when a facility is reached.5 This framework have
been used in different studies and in Pakistan many
Maternal deaths related delays also highlight this
model. Studies from United Kingdom and France
have demonstrated referral rate varying between
1and 28 %.6 while this information provides some
parameters of the level of referral, one might
expect, its Setting-France – is not comparable to
developing world. A rate of 0.2 5 as seen in the local
study reflect malfunctioning and non-existing of the
system rather than absence of need.7
Recently, other investigators have confirmed the
problem and identified some of its causes, such as
inappropriate referral, lack of structure of referral
letters, delay in feedback, inefficient hospital
administration and inadequate resources and
facilities in health centers. In this context, the urgent
need for retraining of all levels of health care
providers and redefining and formalizing the
referral system cannot be overemphasized. Such a
revised would need to incorporate the recognition
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of referral as a two-way process of communication.
Needless to say, Referral system require piloting
and close monitoring before its full-scale
implementation on criteria and principle.7
References
1. Abodurin OL, Akande TM, Osagbemi GK. Awareness and
perception toward referral in health care : a study of adult
residents in IIorin, Nigeria. Annals of medicine..2010;9(3);
176-180.
2. Tabish S. Referral System in Health Care.2010. Referral
System in Health Care. Available @URL:
https;//www.researchgate.net/publication26195757501_R
efferal_System in Health Care [Cited July 27, 2018]
3. Health Systems Profile- Pakistan Regional Health Systems
Observatory- EMRO.2007 [Internet] Available from
http://apps.who.int/medicinedocs/documents/s17305e/s1
7305e.pdf
4. National Health Insurance Scheme. Operational
Guidelines. 2012 [Internet] available from:
https://www.dhmlnigeria.com/downloads/NHIS_operation
al_guidelines(revised).pdf
5. Barnes-Josiah D, Myntti C, Augustin A. The “three delays”
as a framework for examining maternal mortality in Haiti.
Social science & medicine. 1998;46(8):981-993.
6. An Mizrah, Ar Mirzah. Les séances de medecin;specialite,
contenu et prix. Enquete sur la sante et soins medicaux
1991-1992, Paris: CREDES. June 1994.
7. S Siddiqi, AA Kielmann, MS Khan, Nabeela Ali, A Ghaffar,
Unaiza Sheikh, health policy and Planning.2001;
16(2):193-198.
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